Healthcare Provider Details

I. General information

NPI: 1972260594
Provider Name (Legal Business Name): TYLER GANSEN OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2021
Last Update Date: 11/18/2021
Certification Date: 11/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10273 YELLOW CIRCLE DR
MINNETONKA MN
55343-9144
US

IV. Provider business mailing address

10273 YELLOW CIRCLE DR
MINNETONKA MN
55343-9144
US

V. Phone/Fax

Practice location:
  • Phone: 952-401-9359
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: